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R 5899 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 589 9 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (4DB)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADD/REBS // __ Lo 0 q Vii OYI,4*3 W RESIDENTIAL_(,_COMMERCIAL OTHER OWNERS HAZARDOUS FIRE AREA NAME E 14 O44 M/4,1yF-h YES ❑ If yes—I understand that a Claw roof assembly is required. NO ❑ Initial I.C.B.O.S ADDRESS Z01 lj4 L4 ,L/OPLdikS W,y EXISTING ROOF COVERING PHONE 253 44 T i/�� NUMBER OF EXISTING COVERINGS CONTRACTOR'S f NAME W 1 i�L TO BE REMOVED I TO BE RETAINED ADDRESS TYPE OF ROOF COVERING CITY a ZIP 10 314 LBS OncGaS in1A•G, . Cuyc ggoo EXISTING PHONE 2S2- SIQ.a BUILT-UP ROOF ❑ LICENSE NUMBER 47 L4011 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION ��/ hereby affirm that em licensed under provisions of Chapter 9(commencing with WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license is in lull force effect. q p o WOOD SHINGLES ❑ License Claes `� 3 1 Lic.Number Contractor Date (o Z<- OTHER(SPECIFY) El OWNER-BUILDER DECLARATION 'PROPOSED I hereby affirm that I em exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct.alter,Improve,demolish,or repair any structure.prior to its issuance,also requires the BUIbT ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions A s IL- -UP ROOF of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged SPHALT SHINGLES , L(o LICA— , exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 111 2 , �rg Ppy�siC�K^ x a civil penalty of not more than five hundred dollars($500)): V V 2 - 1 E]1,as owner of the property,or my employees with wages as their sole compensation,will do HAKES ❑ the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Pr��I9' sions Code:The Contractor's License Law does not apply to an owner of property who buIT91 Y V- vv VMD'SHINGLES ❑ Improves thereon,and who does such work himself or through his own employees,provided that such improvements are not Intended or offered for sale.ll,however,the building or improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or improve tar purpose of sale.). ❑I,is owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFG R. INSTALLATION SPECS. [II am exempt under Sec. ,B 8 P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building provided for by Section 3700 of the Labor Code,for the performance of the work for which this T permit is Issued. r'` 8 8 000 Seismic �© ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of 1 _the Labor Code,for the performance of the work for which this permit Is issued.My Worker's l Compensation insurance carrier and Policy number are: Total l 2 7 r 0 Carrier —pt'�x`4 Ir' Policy No. 14 813(p y' PERMIT AUTHORIZATION DATE CERTIFICATE EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section need not be completed if the Permit Is for one hundred dollars($100)or less.) Q r I certify that in the performance of the work for which this permit is Issued,I shall not employ (z— LLLCCC/// r bm Berson In any manner$0 as to become subject to the workers'Componsallon Laws of call. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an Date 4 z4 93 Applicant �� inspection,I agree to remove all new materials for inspection. NOTICE AP ICANT: II,after making this Certificate of Exemption,you should become A Ilcant understands and will I with all subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply y wanon point with such provisions or this permit shartbe deemed revoked. source regulations. I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"Or better. hereby authorize representatives of this coy to anter upon the above-mentioned property for in. i apache)purposes. 2 L/qg (We)agree to save,indemnify and keep harmless the Clry of Cupertino against Ilebillliae, judgments,coats and expenses which may In any way accrue against said City In coneequenca of the granting of this permit. SIGNATURE OF APPLICANT ATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY